7 Brockman Street

GINGIN WA 6503

Tel: 08 9575 2211

Grants email:

ABN: 85 679 704 946

2018/19Public Liability Insurance Grant Application – FORM C

IMPORTANT: Before you apply for a grant please ensure that:

You have read the Community Grants Guidelines2018/19 and application checklist (last page of grant application). For projects or events please use the Community Grants 2018/19 Application Form – FORM B.

You complete all application requirements including answering all questions

Your attachments to this application by email are no larger than 4MB

Please Note: Late applications will not be considered for funding.

  1. Application Information

Organisation name:
Street Address:
Suburb / Postcode:
Postal Address:
Suburb / Postcode:
Contact person: / Role:
Telephone: / Mobile:
Email:
Website address: / Incorporated: Yes No
ABN: (if applicable) / GST Registered: Yes No
Sum requested from Shire of Gingin:
(Note: 50% Public Liability Insurance or $800 whichever is lessor amount)
  1. Information about your organisation(What it does, for whom and where?)

What is the primary purpose of your organisation?
What is your main target group?
How many people receive services directly from your organisation per year?
How many additional people, in the wider community, receive an indirect benefit from your organisation (per year)?
What year was your organisation established?
Number of members (if relevant): / Membership fee:
Who owns the premises from which you operate your service?
Has the Shire of Gingin previously assisted your organisation?Community Grant and/or Mid-Year Grant (Small Project/Event) / Yes No

5. DECLARATION:

This Declaration is made by the applicant and,

  • I declare that all the information is true and correct.
  • I give permission to the Shire of Gingin to contact any persons or organisations in the assessment of the application and understand that information may be provided to other agencies, as appropriate.

Applicant Signature: / Date:
Chairperson/President/Authorised Person
Print Name: / Title:
Position:
Witness name:
Witness signature:

APPLICATION CHECKLIST

Copy provided with application (attachment):

Current Certificate of Incorporation; Insurance Certificate of Currency

Most recent financial statement Most recent Public Liability Insurance Invoice

Community Grants 2018/19 Funding Deadline:Monday, 19 March 2018, 9am

The completed Application and attachments are be sent to:

By email:Signed and scanned Applications to:

By post:Shire of Gingin

Community Funding Scheme

PO Box 510

GINGIN WA 6503

In person:Shire of Gingin Administration Centre

7 Brockman Street

GINGIN WA 6503

Or

Shire of Gingin Lancelin Office

255 Vins Way

LANCELIN WA 6044

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